Gustilo Anderson Classification of Open fracture
Progression for grade I to III C implies a higher degree of energy involved in the injury, higher soft tissue and bone damage, and higher portential for complications.
Type I: <1 cm; Mild/minimal energy trauma, soft tissue injury, contamination or communition
Type II: 1-10 cm; Moderate energy trauma, soft tissue injury, contamination or communition
Type III: >10 cm; Severe/extensive energy trauma, soft tissue injury, contamination or communition or segmental fractures
These are automatically Type III open fractures:
- Fractures >8 hours old
- Farmyard injuries
- Gunshot injuries
- Traumatic amputation
- III A: Adequate soft tissue coverage of bone
- III B: Bony exposure
- III C: Compromise of neurovascular status
Mangled Extremity Severity Score (MESS) to Predict Eventual Amputation
1. Maturity (Age):
- <30 years: 0
- 30-50 years: 1
- >50 years: 2
2. Extremity ischemia:
- Pulse reduced or absent but perfusion normal: 1
- Pulseless (by doppler), paresthesia, diminished capillary refilling, diminished motor activity: 2
- Pulseless, cool, paralysed, insensate, numb, without capillary refill: 3
3. Skeletal and soft tissue injury:
- Low energy: 1
- Medium energy: 2
- High energy: 3
- Very high energy (crush): 4
- Normotensive: 0
- Transient hypotension: 1
- Persistent hypotension: 2
- Score is doubled for ischemia >6 hours.
- MESS >7 predicts eventual amputation.
Emergency Room Management of Open fracture
Follow the trauma protocol and stabilize the patient with primary survey followed by secondary survey.
1. Prevention of further contamination:
- Take wound swab cultures
- Photograph the wound
- Cover the wound with sterile dressing soaked in saline or povidone-iodine
2. Prevention of bacterial growth:
- 6 hour golden rule: All open fractures should be regarded as surgical emergencies and shouldbe definitively treated within 6 hours of injury. But the current evidences suggest that operative care may be delayed upto 24 hours.
- Empirical IV antibiotics in maximum dose:
- Type I and II injuries: 1st generation cephalosporin
- Type III injuries: Add aminoglycoside
- Suspected anaerobic contamination: Add metronidazole
Rule of 3 for antibiotics: Initiate antibiotics as soon as possible (possibly within 3 hours) and continue for atleast 3 days.
Reference: Frontiers in Fracture Management By Timothy D Bunker, Christopher L Colton, John K Webb